Abstract
Purpose To review the risk factors and pathogenesis of endothelial decompensation after penetrating keratoplasty (PKP) and its novel therapeutic strategies. Methods Literature review. Results As the major cause of graft failure in PKP, endothelial decompensation of corneal allograft is considered an irreversible decrease in endothelial cell density and endothelial dysfunction. Various risk factors, including donor status and operative and recipient factors, have been found to be associated with this pathological process. Operative factors like graft size and recipient factors such as indications, glaucoma, or glaucoma surgery history are highly associated with the occurrence of endothelial decompensation, while others are still under investigation. Although the mechanism of these risk factors remains unclear, pathogenesis can be summarized as an acute and chronic loss of endothelium, and cell exchange between donor and recipient is at the core of chronic cell loss. Endothelial keratoplasty has been a useful alternative to repeat standard PKP in eyes with failed grafts. Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet's membrane endothelial keratoplasty (DMEK) following failed PKP provide more rapid visual recovery and achieve better rates of graft survival than those of a second PKP. Conclusions Any direct or indirect damage to the endothelium could cause the loss, morphological changes, and dysfunction of endothelial cells. Graft size, indications, and recipient glaucoma or glaucoma surgery history are risk factors for endothelial decompensation. DSAEK and DMEK are novel therapeutic strategies for failed PKP grafts and have potential superiorities compared with repeat PKP.
Highlights
For more than half a century, penetrating keratoplasty (PKP) has been the most common allograft surgery and caters successfully to most causes of corneal blindness, including stromal or endothelial disease
Since the normal function of endothelial cells is crucial for the maintenance of corneal transparency, the accumulative loss of endothelial cells might reach a minimum threshold, followed by functional decompensation resulting in corneal edema and opacity. is irreversible reduction in endothelial cell density (ECD) and endothelial dysfunction of the corneal graft is defined as graft endothelial decompensation [16]
Is endothelial keratoplasty a better choice for patients with endothelial decompensation following PKP? We summarize current evidence regarding this subject and comparison between the three procedures shown in recent research, there remain some conflicts on which one should be the step of visual rehabilitation
Summary
For more than half a century, penetrating keratoplasty (PKP) has been the most common allograft surgery and caters successfully to most causes of corneal blindness, including stromal or endothelial disease. The mechanism of these risk factors remains unclear, the indication for initial PKP is an important factor affecting the incidence or even the onset time of endothelial decompensation [16]. Other factors, such as intraocular pressure (IOP), graft size, and history of diabetes of the donor, have started to draw researchers’ attention, despite the controversial results of current studies [3, 7, 10, 11]. With recent advances in lamellar corneal surgery, surgeons subsequently began to consider the option of endothelial keratoplasty (EK) for post-PKP patients with endothelial decompensation [18]. We compare graft survival, visual recovery, and the occurrence of related complications, such as graft dislocation and graft rejection, among DSAEK, DMEK, and repeat PKP
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